Carotid Artery Stenting Safety Effectiveness with protection

Carotid Artery Stenting Safety & Effectiveness with protection Makoto Negoro, MD Irie K, Hayakawa M, Sadato A Dept of Neurosurgery Fujita Health University

Topics n Case Summary n Technical Difficulty n Protection n Hyperperfusion Syndrome ? Dept of Neurosurgery Fujita Health University

Stenting for Extracranial Carotid Stenosis at FHU > 60 - 70% stenosis, Symptomatic n Associated Diseases (Coronary A) n Higher Cervical Lesion n Contralateral Occlusion or Stenosis n Restenosis after CEA or PTA n Stenosis or Blowout after Irradiation n Asymptomatic ? n Dept of Neurosurgery Fujita Health University

Case Summary 2002/1 ~ 2007/12 116 cases n Distal Balloon Protection (PKS) n Wall stent or Smart stent n 2008/1 ~ 2010/ 9 127 cases n Filter Protection n Angioguard n Filter Wire EZ n Balloon Protection (Distal or Proximal) n Precise or Wall stent n Dept of Neurosurgery Fujita Health University

Complication & Restenosis n Before 2008 (116 cases) Transient Ischemia 4 n Cholesterol Crystal syndrome 2 n Restenosis 2 n n After 2008 (127 cases) Transient Ischemia n Fixed Ischemia n Hemorrhage (Hyperperfusion ? ) n Restenosis n Cholesterol Crystal syndrome n 4 1 2 1 1 Dept of Neurosurgery Fujita Health University

Technical Difficulties Aortic Arch Configuration n Angulation of Internal Carotid Artery n Severity of Stenosis n Severe Stenosis n Nearly Occlusion n Dept of Neurosurgery Fujita Health University

Lt ICA Stenosis, ASO 78 y, male, Asymptomatic n So called, Bovine Arch (Rt transbrachial A approcah) Dept of Neurosurgery Fujita Health University

Dept of Neurosurgery Fujita Health University

Dept of Neurosurgery Fujita Health University

Severe Stenosis　78 y male, symptomatic Dept of Neurosurgery Fujita Health University

Dept of Neurosurgery Fujita Health University

Dept of Neurosurgery Fujita Health University

Dept of Neurosurgery Fujita Health University

Dept of Neurosurgery Fujita Health University

Lt ICA Occlusion ? 75 y, male, Symptomatic Dept of Neurosurgery Fujita Health University

Dept of Neurosurgery Fujita Health University

Protection Rationale : always plaques ? Without Protection, More than 40% has diffusion MRI abnormality after stenting ? Dept of Neurosurgery Fujita Health University

Distal Balloon Protect Percu. Surge Guard Wire Dept of Neurosurgery Fujita Health University

Proximal Balloon Protection Dept of Neurosurgery Fujita Health University

Filter Device A Accu. Net B Angio. Guard C Filter. Wire EZ* D Intercepter E Intra. Guard F Neuro. Shield (* Eccentric) Dept of Neurosurgery Fujita Health University

Filter Device K G Rubicon H Sci-Pro I Spider * J Trap NFS K Emboshield Dept of Neurosurgery Fujita Health University

Pros & Cons of Protection Hendrick, 2004 Dept of Neurosurgery Fujita Health University

Comparison of Protection n CAS EPD n Angioguard n Filter. Wire EZ n Spider Flow impairment n Filter Obstruct n Spasm 115 cases 68 (59%) 32 (28%) 15 (13%) 25 (22%) 21 (18%) 4 ( 4%) n n Frequency of Flow Reduction n Angioguard 22/68 ( 32. 3 %) n Filter. Wire EZ 2/32 ( 6. 2 %) n Spider 1/15 ( 6. 7 %) Frequency of No Flow n Angioguard 13/68 ( 19 %) n Filter. Wire EZ 0/32 ( 0 %) n Spider 0/15 ( 0 %) n 2 stroke( 8%) in flow reduction Roffi, M (2008) Dept of Neurosurgery Fujita Health University

Dept of Neurosurgery Fujita Health University

Hyperperfusion Syndrome ? 70 y, male symptomatic Dept of Neurosurgery Fujita Health University

Pre Post Dept of Neurosurgery Fujita Health University

CBF Pre Dept of Neurosurgery Fujita Health University

CBF post Dept of Neurosurgery Fujita Health University

6 days later, Dept of Neurosurgery Fujita Health University

Conclusion n Experienced operators can perform CAS without much difficulties. n Selection of Patient & Devices is critical n Hyperperfusion remains as Unsolved Problem Dept of Neurosurgery Fujita Health University